The dilemma emerged in decade of 1980s due to rising number of unemployed people who were not able to possess their right of HI because right was connected to professional status only.
The change on French HC system began in 1996 through “Juppe reforms”. This reform introduced major changes in the French HI system firstly contributions based upon wages which were like tax on income were replaced by contribution based on total income. Secondly, increased the role of parliament in deciding policy directions and expenditure targets. (Sandier et al, 2004, p. 5-11)
The biggest strength of France came up with most vital reform CMU “Couverture maladie universelle” or Universal Health coverage act took place in June 1999 which came into affect from Jan 2000. This act provided right to statutory HI to entire population of France on basis of resident of country. This act provided free coverage to the people whose income found to be below certain level. Thus French Health system took care of poor sections of country.
(Elkan, 2003)
Currently there are three key Health Insurance (HI) schemes in France. General HI scheme (regime general), Agricultural scheme, Non agricultural self employed scheme and poor sections of people are covered as CMU beneficiaries.
(Sandier et al, 2004, p.5-11)
The financial and operational management of all these HI funds are controlled by state like setting premiums of insurance or keeping prices of health services.
The social security system of France is managed by both state parliament and directors of Health insurance funds with divided responsibilities to each of them. These directors are elected through elections among employers and employees itself.
The Organisational structure and regulation of HC system of France is broadly divided between three bodies. State government which includes Ministry of health and parliament, Local committees but their role is very less and Health Insurance funds.
(Sandier et al, 2004, p.19)
After “Juppe reforms “of 1996, the state parliament forms health policies, allocates resources and control HC system. The state sets the projected target or budget for the HI expenditure. It is known as Annual social security funding act (ONDAM) which sets national ceiling on health expenditure.
The Ministry of health has four Directorates in centre i.e. General directorate of health who forms health policies, Directorate of Hospital and health care who manage the operations of HC institutions and allocate resources efficiently, Directorate of social security who manages the financial system and supervises social security organisations like Health insurance funds and Directorate of social policy who runs the social aspects of HC system like care of old and disabled people.
There are sub directorates of social and health affairs at regional levels (DRASS and DDASS) which are connected to centre. All the health expenditures are controlled by Ministry of health as advised by parliament. The budget is allocated to hospitals according to needs of region. Health ministry approves the agreement between doctors and HI funds. It sets the prices for various medical procedures, sets up physician fees, premiums for health insurance, reimbursement policies, intake of students in medical school, decisions regarding purchase of new equipments and medical technologies for hospitals and launch of various national health programmes.
Along with state health ministry government of France has made few committees and agencies which have their independent authority in running French HC system. These committees analyses health status of citizens and their health problems then prepare reports and propose solutions to state. These committees lays practice guidelines for doctors, carries out accreditation process for both public and private hospitals and pharmaceutical industry, promotes development of clinical skills in HC professionals by providing latest training in medical field. Hence such committees assist ministry of health for smooth running of HC system. For example National agency for Accreditation and evaluation of health care (ANAES). (Sandier et al, 2004, p.19)
Regarding hospitals, France has three types of Hospitals i.e. Public, Private profit making and Private non profit making hospitals. Mostly 75% of all hospitals beds are placed in public hospitals. (Green et al, 2001, p.44)
Public hospitals are big well equipped with medical facilities and grants opportunity of learning, practical training and research to medical students. In France there are 1050 Public hospitals with 323100 beds in 2001 (5.5 beds for 1000 people in 1998).Public hospitals are further subdivided into Regional hospitals, Hospital centres and local hospitals providing latest HC facilities at different levels.
Private non profit hospitals are like public hospitals and follow same rules of financing and operations except employment of staff. These hospitals have 24782 beds. There are 20 cancer centres running under these hospitals.
Private for profit hospitals are 20% of total hospital capacity of France. They mainly deal with acute medical care like surgeries. There were around 98814 beds in these hospitals.
Public Hospitals work under budget assigned by the state and doctors are salaried. In Private hospitals specialists are paid fee on service system and are allowed to run their own practice. In fact French Public hospitals are well equipped with latest medical technologies. Thus provides high class medical treatment and are highly responsive to patient needs and provide consumer satisfaction which makes its system applauded all over world.
The private for profit hospitals do not have any fixed budget. The regional agencies sign contract with them. These contracts specify spending limits and activities of the hospitals. The fees or payments in private hospitals are regulated according to NHI rules.
(Green et al, 2001, p.44)
Regarding health care funding in France, The HC budget of France is highest in Europe and third largest in world at 9.4% of GDP. This is divided between NHI (75.5%), private insurers (12.1% VHI), General taxation (1.1%) and left 11.3% amount was borne by patients as out of pocket payments. (Green et al, 2001, p.32)
The funding for health care facilities and expenses in France are mainly borne by statutory HI under the social security system. This system has mainly three schemes. General HI scheme (regime general) covering employees working in Industries and commerce along with families (84% of citizens), Agricultural scheme (Mutualite sociale agricole) covering agriculture workers (7.2% of citizens), Non agricultural self employed scheme (CANAM) covering self employed non agriculture workers like lawyers, businessmen, artists etc (5% of citizens). And poor sections of society are covered as CMU beneficiaries (1.6% of citizens). General scheme is connected with few other schemes which cover certain categories of population like National civil servants, doctors working with state health agreements and few people like students and military personals.
(Sandier et al, 2004, p.36)
Under this system patients health expenses are either paid directly to the hospital or the payment is made by patient and then reimbursement is done by HI fund of “securite sociale”. (Weill, 1995, p.1105)
As reimbursement is not 100% by social HI system. So, people prefer to attain additional Private HI to supplement government run social HI. 90% of French people have private insurance to cover co payments. (Coeffinhal, 2007)
Health Insurance “securite sociale” in France is funded by compulsory contributions by both employers and employees. French employees are liable to contribute around 20% of their gross salary as premium to HI. Presently employers pay 12.8% of gross earning and employee pays (7% recently decreased to 0.5%) but introduced additional contribution of 7.5% on the total income earned from employment, self employment, share dividends or interests hence it is more fairer to the employees. (Green et al 2005)
French HC system has merit of providing Equity in HC. France provides coverage to all people who are unemployed or poor and can not contribute to HI fund. These people come as CMU beneficiaries. France introduced law of Universal Health coverage (CMU) which provides health access to HI to every legal resident of France instead of its employment status. Moreover people who earn less than 6600 euros also comes under CMU and are not suppose to contribute. (NCHC, 2007)
Regarding reimbursement in French social HI system, 84.9 % of statutory health HI expenditure goes as reimbursement of HC claims by patients. HC expense claims are partially reimbursed either directory to the provider or repaid to the insured person. The left 15.1% of HI expenditure is used for allowances to insured people like sudden accidental treatment, Maternity treatment and pensions to old and disabled people.
French social HI has merit of providing coverage for variety of medical treatments including major surgeries to spa treatments. The reimbursement varies according to treatment. Generally it is around 70%.
The policy of reimbursement is based on 3 principals. Firstly “the health insurance system grants access to registered health care professionals of their choice”. Secondly “there is no limit of volume of goods and services reimbursed even thermal spas”. On the other hand to avoid excessive consumption and curb moral hazards co payments are implemented which are raised with time. Thirdly “The doctors have considerable freedom prescribing, although they must comply practice guidelines”. So it is favourable to both Patients and physicians. (Sandier et al, 2004, p.36)
As general rule patients are suppose to pay at first point of delivery and then claim back the expenses from HI funds which directly come in patient bank account. This rule is applied neither in the case of Hospital admission where HI fund directly pay the concerned hospital nor in the case of CMU beneficiaries (poor people HI). Direct payments are also given to pharmacies and laboratories. So system is hassle free to access. (Owen, 2007)
The State sets the fee structure for the doctors. French system provides freedom of choice to the patients to visit any physician or specialist without any referral from GP. Mostly people visit the doctors which work under “securite sociale” system. They charge the fee as set by HI system and are known as Conventional doctors. Some doctors may charge more fees but reimbursement is done according to the standard fee set up by social HI. Those doctors who do not work under “securite sociale” are Unconventional doctors.
(Sandier et al, 2004, p.36)
In “securite sociale” patient is reimbursed with around 70% of fee. Patient pays only 30% to visit physician, 40% to visit specialist and 15% to visit GP. Drugs are sold through pharmacies and reimbursement varies according to type of drug. Reimbursement of some drugs is 100% some 65% and few only 35% like multivitamin drugs. (Coeffinhal, 2007)
Treatment expenses in Public hospitals are reimbursed 80% in first month and 100% from 31st day or for major surgery and maternity care. But there is only 10% reimbursement in Profit private hospitals.
(NCHC, 2007)
French HC system has bunch of merits. Although it do have demerits but its variety of strengths outshines its weaknesses which makes it top HC system in World.
Highlighting weaknesses, French HC system is very complex due to co existence of Public with Private Health sectors and separate HI fund. So there is always possibility of conflict between them regarding policies. France is worried of its ageing population, low fertility rate, advancement in medicine and increasing expectations of people which tend to put pressure to spend more in HC. There are very high levels of reimbursement which makes it most expensive system. In 2005, France spent 10.6% of its GDP for HC. If it continues at same pace then country will be in 70 billion euros in debt by 2020. Due to freedom of choice patients “shop” for doctors i.e. consulting different specialists until they get desired diagnosis. (NCHC, 2007)
There is overuse of prescription drugs. French parliament is trying its best to control budget by putting “ceiling” on expenditure but still unable to stop overspending. There is fear of shortage of doctors due imposition of quotas in medical Institutions. There had been conflicts regarding ceiling on physician fee. Many unions of physicians even refused to sign agreement with HI system.
(Sandier et al, 2004, p.19)
French HC system shines because of its various merits and strengths which has brought it to top position. It outperforms even NHS of UK and American HC system. It provides sufficient satisfaction to their citizens that 78.2% of French people are happy with the system. Thus justifies its expensiveness.
French HC system is Social Insurance based and on principle of equality. Even American system is Insurance based but unlike America, France provides Social insurance to each and every legal resident regardless of its employment status or income. But in America poor people without HI just rely on mercy of charity.
In France unlike NHS of UK, Patients are immediately seen and if required admitted in hospital without any waiting lists. Patients have full choice of visiting any hospital and consulting any doctor without any referral. Patient has to pay at the point of delivery of care so there is no chance of moral hazards. France put ceiling on medical school admissions and tend to keep supply of doctors in control to prevent competition among doctors which raises the price. France Public hospitals provide latest medical facilities as compared to anywhere in World. Public hospitals are as good as private ones. French people do not feel any difference in treatment or any waiting time in public hospitals.
The French Social HI system rests upon two main negotiations with Physicians and Insurers. Physicians participate in compulsory HI because law protects patient choice of doctor and assures doctors control over medical decisions and therapy.
French law makers also came out from the resistance of Insurance Industry by allowing them to administer new HI funds. Private health insurers are also allowed to cover the patient expenses which are not reimbursed by “securite sociale”. In fact 90% of French people possess private insurance also. (Dutton, 2007)
There is no doubt that France leads the world in Health care system. It shines because of its awesome features of providing Universal health coverage even to the poorest people, Highly responsive health care providers , Freedom to both patients and physicians ,high life expectancy and last but most important is Patient satisfaction which puts France at top.
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